Successful replantation of amputated facial tissues by supermicrosurgery.

BACKGROUND: Although replantation of amputated facial segments remains challenging in reconstructive surgery, it offers excellent aesthetic and functional outcomes. METHODS: From May 2004 to October 2019, 12 patients underwent replantation of amputated facial tissues by supermicrosurgery. The case details, such as the rationale for replantation, the operation method, and postoperative therapy, are described. Four cases are discussed to demonstrate the replantation of different facial parts. RESULTS: Facial tissue replantation was successful in all 12 patients without secondary surgery. The cases included the nose (1 patient), ears (8 patients), lips (2 patients), and one of the soft tissue segments surrounding the lower jaw. Venous congestion occurred in three patients who received a solitary arterial repair and were treated with bloodletting. All patients expressed satisfaction with the cosmetic and functional results at the final follow-up. CONCLUSIONS: Supermicrosurgical facial tissue replantation is a promising and effective procedure for providing patients with the best aesthetic and functional outcomes.

Recent Progress in the Construction of Functional Artificial Bone by Cytokine-Controlled Strategies.

OBJECTIVE: Combining artificial scaffolds with stimulatory factors to reconstruct lost bone tissues is one of the hottest research directions. The purpose of this review was to conduct a retrospective survey on the latest reports on artificial bone fabrication with functional cytokines. DATA SOURCES: The status of related scientific research from the year 2005 to 2018 was analyzed through the mode of literature retrieval in PubMed and VIP Database. The retrieval words are as follows: "bone tissue engineering," "angiogenesis," "cytokines," "osteogenesis," "biomimetic bone marrow," "sol-gel," "delivery system," and the corresponding Chinese words. STUDY SELECTION: After reading through the title and abstract for early screening, the full text of relevant studies was evaluated and those not related with this review had been ruled out. RESULTS: According to the literature retrospective survey, there were three key points for the successful construction of functional artificial bones: (1) the continuous supply of relatively low concentration of cytokines during the required period; (2) the delivery of two or more cytokines essential to the process and ensure the relatively spatial independence to reduce the unnecessary interference; and (3) supporting the early-stage angiogenesis and late-stage osteogenesis, respectively, regulating and balancing the crosslinking of both to avoid the surface ossification that would probably block the osteogenesis inside. CONCLUSIONS: The synergistic effect of both angiogenic factors and osteogenic factors applied in bone regeneration is a key point in the combined functional artificial bone. Through analysis, comparison, and summary of the current strategies, we proposed that the most promising one is to mimic the natural bone marrow function to facilitate the regeneration process and ensure the efficient repair of large weight-bearing bone defect.

[Association of methylenetetrahydrofolate reductase A1298C polymorphisms with non-syndromic cleft lip with or without cleft palate].

OBJECTIVE: To investigate the association between a polymorphism of methylenetetrahydrofolate reductase with Non-syndromic cleft lip with or without cleft palate (NSCL/P) in Chinese population. METHODS: The polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP) technique was used to detect a single nucleotide polymorphism (SNP), rs1801131, at the methylenetetrahydrofolate reductase (MTHFR) gene in both 158 patients with NSCL/P and 192 healthy individuals. The Hardy-Weinberg equilibrium for genotypic distributions was estimated by the goodness-of-fit test. The UNPHASED program was applied to perform the association analysis. RESULTS: The genotypic distribution of A1298C was not deviated from the Hardy-Weinberg equilibrium in both controls and patients. No association was found between cleft lip with or without palate (CL/P) and controls. There was significant difference of cleft palate only (CPO) and the healthy individuals (χ(2) = 4.256, P = 0.039). The frequency of AC + CC genotype was higher in control group than that in CPO group (OR = 0.8, 95%CI = 0.381 - 1.683), 26 among 100 healthy individuals carried AC + CC genetypes, which were carried by 22% of CPO patients. CONCLUSIONS: The polymorphism of MTHFR A1298C may be involved in the occurrence of non-syndromic cleft palate only in Chinese population.

An experimental study of artificial murine bladder reflex arc established by abdominal reflex.

BACKGROUND: The neurogenic bladder dysfunction caused by spinal cord injury is difficult to treat clinically. The aim of this research was to establish an artificial bladder reflex arc in rats through abdominal reflex pathway above the level of spinal cord injury, reinnervate the neurogenic bladder and restore bladder micturition. METHODS: The outcome was achieved by intradural microanastomosis of the right T13 ventral root to S2 ventral root with autogenous nerve grafting, leaving the right T13 dorsal root intact. Long-term function of the reflex arc was assessed from nerve electrophysiological data and intravesical pressure tests during 8 months postoperation. Horseradish peroxidase (HRP) tracing was performed to observe the effectiveness of the artificial reflex. RESULTS: Single stimulus (3 mA, 0.3 ms pulses, 20 Hz, 5-second duration) on the right T13 dorsal root resulted in evoked action potentials, raised intravesical pressures and bladder smooth muscle, compound action potential recorded from the right vesical plexus before and after the spinal cord transaction injury between L5 and S4 segmental in 12 Sprague-Dawley rats. There were HRP labelled cells in T13 ventral horn on the experimental side and in the intermediolateral nucleus on both sides of the L6-S4 segments after HRP injection. There was no HRP labelled cell in T13 ventral horn on the control side. CONCLUSION: Using the surviving somatic reflex above the level of spinal cord injury to reconstruct the bladder autonomous reflex arc by intradural microanastomosis of ventral root with a segment of autologous nerve grafting is practical in rats and may have clinical applications for humans.

A thermosensitive chitosan-based hydrogel barrier for post-operative adhesions' prevention.

Post-operative peritoneal adhesions are common and serious complications for surgeons. They can cause pelvic pain, infertility, and potentially lethal bowel obstruction. We synthesized injectable hydrogels that formed by chemical modification through grafted hydrobutyl groups to chitosan chains. Gelation of hydroxybutyl chitosan (HBC) occurs in less than 60 s. Once formed, it can also be recovered completely. The residue time of hydrogels can extend to 4 weeks in Kunming mice. HBC hydrogels showed mild cytotoxicity to mice fibroblast cell (L929) and human vascular endothelial cell (ECV-304) in vitro and were biocompatible in the murine muscles, causing no adhesions for 4 weeks. HBC gels can form a durable barrier between defected cecum and abdominal wall. In a mice sidewall defect-bowel abrasion model, HBC gels showed significant efficacy in reducing adhesion formation.

Reconstructed bladder innervation below the level of spinal cord injury: the knee-tendon to bladder artificial reflex arc.

BACKGROUND/OBJECTIVE: To study the effectiveness of knee-tendon to bladder artificial reflex arc in dogs. METHODS: In 6 beagles, the proximal end of the right L5 anterior motor root and the distal end of the right S2 anterior root were anastomosed to build a knee-tendon to bladder reflex, whereas the right L5 posterior sensory root was kept intact. Action potential (AP) curves and electromyograms (EMGs) of the detrusor muscle, the intravesical pressure, horseradish peroxidase (HRP)-labeled neurons, and the passing rates of myelinic nerve fibers were calculated to evaluate its feasibility. RESULTS: AP curves and EMG detected in all 6 dogs were similar to those of the control. Six and 18 months after surgery, the means for bladder contraction induced by percussion of the right knee-tendon were 38 +/- 27% and 62 +/- 5% that of the normal control, respectively. The mean duration times induced by percussion of the right knee-tendon at 6 and 18 months after surgery were 51 +/- 37% and 84 +/- 12% that of the normal control, respectively. HRP retrograde tracing and neurohistologic observation indicated the feasibility of the artificial reflex arc. CONCLUSIONS: Our data showed the effectiveness of bladder innervation below the level of spinal cord injury producing urination by knee-tendon to bladder reflex contractions, and therefore, might provide a new clinical approach for restoring bladder function in individuals with paraplegia.

An overview of skin flap surgery in the mainland China: 20 years' achievements (1981 to 2000).

Microsurgical anatomy and clinical applications have been widely and extensively practiced throughout the mainland of China since late 1970s. During the 1980s to 1990s, Chinese surgeons and anatomists developed many new flap donor sites and modifications, most of which were published in Chinese literature. These achievements were not fully realized by the Western surgeons. In this overview, we attempt to give a brief introduction of these contributions made by the Chinese authors in the mainland. Of the new flaps first or independently described by the Chinese, most were in the limbs. These flaps can be classified into three categories. First are free flaps with a main artery trunk, such as the radial forearm flap with radial artery, the medial leg flap with posterior tibial artery, and lateral leg flap with peroneal artery. Second are reverse-flow island flaps based on distal main vascular bundles (e.g., the radial artery and venae comitantes, the ulnar, the posterior tibial, and the peroneal arteries). Third are septocutaneous perforator flaps that avoid sacrifice of the main artery trunk, which include the anterolateral thigh flap, lateral lower-leg flap, dorsoulnar flap, distally adipofascial pedicled radial forearm flap, and so on.

Staggered rhizotomy of anterior and posterior sacral roots for bladder reservoir function in spinal cord injury: a canine experimental study and preliminary clinical report.

OBJECTIVE: To report an experimental study and preliminary clinical results of staggered anterior and posterior sacral rhizotomy for restoring function of the bladder and preventing reflex incontinence in supra-conal spinal cord injury (SCI). METHODS: Ten T10 spinal cord transected mongrel dogs were divided into three groups. In group 1 (n= 2), laminectomy only was performed (control). In group 2 (n= 4), all L7-S3 posterior roots were microsurgically cut (complete deafferentation). And in group 3 (n= 4), the L7, S1, S3 posterior roots and S2 anterior root were cut (staggered deafferentation and deefferentation). Intraoperative electrical stimulation and postoperative cystometrography (CMG) were carried out. In the clinic, three patients with spastic bladder caused by a supra conal complete SCI underwent staggered rhizotomy and were followed up for 6 years. RESULTS: In the canine experimental study, resection of the S2 anterior root combined with L7, S1 and S3 posterior rhizotomy, stimulating the S2 posterior root (four dogs) resulted in a minimal rise in pressure in the bladder and urethra, which was only about 10% of that obtained by stimulating the S2 proximal posterior root while its anterior counterpart was intact (eight dogs, Student's t-test, P < 0.01). The CMG study showed that groups 2 and 3 had similar volume/pressure curves; in both groups the tendency was to develop flaccid bladders. In the clinic, three cases underwent staggered rhizotomy of the anterior and posterior roots in S3 and S4. Good bladder reservoir and compliance was achieved over six years of follow-up. CONCLUSION: Staggered rhizotomy of the anterior and posterior sacral roots at different spinal cord levels has the same denervation effect as a complete posterior rhizotomy, and good bladder reservoir function can be achieved by this procedure.

[Early open reduction of acute incarceratied metacarpophalangeal dislocation].

OBJECTIVE: To explore the mechanism and the treatment of acute incarcerated metacarpophalangeal dislocation. METHODS: Seven patients (6 male and 1 female) with acute incarcerated metacarpophalangeal dislocation admitted from 1997 to 2006 were studied retrospectively. The age ranged from 8 to 33 years(mean 17 years). All the types were the dorsal dislocation. The dislocation were occurred on index finger in 3 cases, thumb in 2 cases, middle finger in 1 case and small finger in 1 case. RESULTS: All the patients were followed up from 3 to 42 months with an average time of 21 months. Operative finding revealed the rupture of volar capsule and entrapment of metacarpal head. The joint function and postoperative X-ray showed anatomical reduction were good in all the patients. CONCLUSION: Repeated manipulative reduction should not be advocated if the close reduction was not successful. In order to avoid influencing the joint function,early open reduction of acute complex metacarpophalangeal dislocation is necessary.

[Clinical observations of the effects on the lower limb function after lumbar or sacral nerve root transferring to reconstruct urination function].

OBJECTIVE: To observe the effects on the lower limbs function after lumbar or sacral nerve root transferring to reconstruct urination function. METHODS: Nine patients with bladder dysfunction and normal lower limb function after spinal cord injury were treated with anastomosis the S2 or S3 nerve root with the normal lumbar or sacral nerve root to reconstruct a new bladder artificial reflex arc. Then the alterations on the sensation and motor function of the lower limb after the surgery were observed. RESULTS: Myodynamia of the legs decreased slightly, and the decreasing about half grade of the myodynamia in the plantar flexion of the ankles were detected in 4 of 9 patients with S1 transferring. And the myodynamia recovered 3 months postoperatively. No obvious decreasing of the myodynamia appeared in the other cases. CONCLUSION: No obvious effects on the motor function can be found after the single lumbar or sacral nerve root transferring to reconstruct urination function.

Reconstruction of reflex pathways to the atonic bladder after conus medullaris injury: preliminary clinical results.

Neurogenic bladder dysfunction following spinal cord injury is a major medical and social problem for which there is no ideal treatment strategy. In this study, spinal root anastomoses were performed in 10 paraplegic patients with traumatic lesions of the conus medullaris, in an attempt to reinnervate the paralyzed bladder. For the operation, the functional T11 ventral root (VR) above the lesion was transected and anastomosed to the S2 ventral roots unilaterally through a nerve graft. The T11 dorsal root was left intact as the trigger for micturition after axonal regeneration. All patients underwent urodynamic evaluation before surgery and at follow-up. The mean follow-up duration was 2 years. Of the 10 patients, 7 (70%) regained satisfactory bladder control within 18-24 months after VR microanastomosis. In these seven patients, the average bladder capacity decreased from 508 +/- 83 (mean +/- SD) to 370 +/- 59 ml, residual urine decreased from 477 +/- 98 to 35 +/- 11 ml, and urinary infections were not observed. Patients with impaired renal function experienced a full recovery. Three patients failed to show any improvement after the operation. These results suggest that a restitutive process occurs in the bladder following reinnervation from new T11 VR connections to the bladder nerves. Spinal cord lesions that may benefit from such a nerve crossover surgery are those located at the conus, whereby a functional suprasacral nerve can be connected to the sacral roots to bypass the injury in an attempt to restore central connections to the bladder.

Intraocular pressure and endothelium cell counts after cataract surgery with chitosan and sodium hyaluronate (Healon GV): 3-year follow-up results of a randomised clinical trial.

INTRODUCTION: The purpose of this study was to evaluate the long-term effects of chitosan 0.1% and sodium hyaluronate 1.4% (Healon GV(R); Advanced Medical Optics, Santa Ana, CA, USA) on intraocular pressure (IOP) and endothelial cell loss. METHODS: This randomised study comprised 140 eyes of 140 patients with age-related cataracts undergoing phacoemulsification followed by posterior chamber intraocular lens (IOL) implantation; 70 received chitosan 0.1%, and 70 received sodium hyaluronate 1.4%. The IOP was measured with standard Goldman applanation tonometry pre-operatively and 1 day, 1 week, 1 month, 3 months, 1 year and 3 years postoperatively. Endothelial cell counts were performed pre-operatively and 1 week, 1 month, 3 months, 1 year and 3 years postoperatively using a Pro/Koester WFSCM contact endothelial microscope. RESULTS: There were no significant differences found in postoperative IOP levels among the chitosan and sodium hyaluronate groups (P>0.05). No significant differences were found in postoperative mean endothelial cell counts at all time points between the chitosan and sodium hyaluronate groups (P>0.05). CONCLUSION: Chitosan has the same effects as sodium hyaluronate on IOP and endothelium cells counts after cataract surgery and IOL implantation, and therefore may be an alternative ophthalmic viscoelastic device.

Repair of brachial plexus lower trunk injury by transferring brachialis muscle branch of musculocutaneous nerve: anatomic feasibility and clinical trials.

BACKGROUND: There are few effective methods for treating injuries to the lower trunk of brachial plexus, and the curative effect is usually poor. The purpose of this study was to provide anatomic references for transferring the brachialis muscle branch of musculocutaneous nerve (BMBMCN) for selective neurotization of finger flexion in brachial plexus lower trunk injury, and to evaluate its clinical curative effects. METHODS: Microanatomy and measurement were done on 50 limbs from 25 adult human cadavers to observe the origin, branch, type of the BMBMCN and median nerve, as well as their adjacent structures. Internal topographic features of the fascicular groups of the median nerve at the level of the BMBMCN were observed. In addition, the technique of BMBMCN transfer for selective neurotization of finger flexion of the median nerve was designed and tested in 6 fresh adult human cadavers. Acetylcholinesterase (AchE) staining of the BMBMCN and median nerve was done to observe the features of the nerve fibers. This technique was clinically tried to restore digital flexion in 6 cases of adult brachial plexus lower trunk injury. These cases were followed up for 3, 6, 9 and 12 months postoperatively. Recovery of function, grip strength, nerve electrophysiology and muscle power of the affected limbs were observed and measured. RESULTS: The brachialis muscle was totally innervated by the musculocutaneous nerve (MCN). Based on the Hunter's line, the level of the origin of the BMBMCN was (13.18 +/- 2.77) cm. AchE histochemical staining indicated that the BMBMCN were totally made up of medullated nerve fibers. At the level of the BMBMCN, the median nerve consistently collected into three fascicular groups as shown by microanatomy in combination with AchE stain. The posterior fascicular group was mainly composed of anterior interosseous nerves and branches to the palmaris longus. The technique was tested in six fresh cadavers successfully, except that stoma split occurred in one case. Five of the six cases recovered digital flexion 12 months after operation, and at the same time grip strength, muscle power, and nerve electrophysiology also recovered markedly. CONCLUSIONS: The technique of transferring the BMBMCN for selective neurotization of finger flexion is anatomically safe and effective, with satisfactory clinical outcomes.

[Influence of sterilization treatments on continuous carbon-fiber reinforced polyolefin composite].

OBJECTIVE: To evaluate the influence of sterilization treatment on continuous carbon-fiber reinforced polyolefin composite (CFRP) so as to provide experimental reference for selection of sterilization method for CFRP. METHODS: Seventy bars of CFRP were divided into 7 equal groups to undergo sterilization by autoclave, 2% glutaraldehyde soaking, 75% alcohol soaking, ethylene oxide sterilization, and Co-60 gamma ray irradiation of the dosages 11 kGy, 25 kGy, and 18 kGy respectively, and another 10 bars were used as blank controls. Then the bars underwent three-point bending test and longitudinal compression test so as to measure the biomechanical changes after sterilization treatment, including the maximum load, ultimate strength, and elastic modulus. RESULTS: Three-point bending test showed that the levels of maximum load of the all experimental groups were lower than that of the control group, however, only those of the 3 Co-60 irradiation groups were significantly lower than that of the control group and that Co-60 radiation lowered the level of maximum load dose-dependently; and that the levels of ultimate strength of all the all experimental groups were lower than that of the control group, however, only those of the 3 Co-60 groups were significantly lower than that of the control group and that the higher the dosage of Co-60 radiation the lower the level of ultimate strength, however, not dose-dependently. The elastic modulus of the Co-60 25 KGy group was significantly higher than that of the control group, and there was no significant difference in the level of ultimate strength among the other groups. Longitudinal compression test showed that the levels of maximum load and ultimate strength of the 3 Co-60 irradiation groups, autoclave group, and circular ethylene groups were significantly lower than that of the control group, and there was no significant difference in elastic modulus among different groups. CONCLUSION: During sterilized package of CFRP products produced in quantity autoclave sterilization and Co-60 gamma ray irradiation sterilization should be avoided. Ethylene oxide is proposed as the best sterilization method. If gamma ray irradiation is to be used further technology improvement is necessary.

Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage.

BACKGROUND: Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point. METHODS: This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap. RESULTS: The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications. CONCLUSIONS: The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

Restoration of shoulder abduction by transfer of the spinal accessory nerve to suprascapular nerve through dorsal approach: a clinical study.

BACKGROUND: In recent years, transfer of the spinal accessory nerve to suprascapular nerve has become a routine procedure for restoration of shoulder abduction. However, the operation via the traditional supraclavicular anterior approach often leads to partial denervation of the trapezius muscle. The purpose of the study was to introduce transfer of the spinal accessory nerve through dorsal approach, using distal branch of the spinal accessory nerve, to repair the suprascapular nerve for restoration of shoulder abduction, and to observe its therapeutic effect. METHODS: From January to October 2003, a total of 11 patients with a brachial plexus injury and an intact or nearly intact spinal accessory nerve were treated by transferring the spinal accessory nerve to the suprascapular nerve through dorsal approach. The patients were followed up for 18 to 26 months [mean (23.5 +/- 5.2) months] to evaluate their shoulder abduction and function of the trapezius muscle. The outcomes were compared with those of 26 patients treated with traditional anterior approach. And the data were analyzed by Student's t test using SPSS 10.5. RESULTS: In the 11 patients, the spinal accessory nerves were transferred to the suprascapular nerve through the dorsal approach successfully. Intact function of the upper trapezius was achieved in all of them. In the patients, the location of the two nerves was relatively stable at the level of superior margin of the scapula, the mean distance between them was (4.2 +/- 1.4) cm, both the nerves could be easily dissected and end-to-end anastomosed without any tension. During the follow-up, the first electrophysiological sign of recovery of the infraspinatus appeared at (6.8 +/- 2.7) months and the first sign of restoration of the shoulder abduction at (7.6 +/- 2.9) months after the operation, which were earlier than that after the traditional operation [(8.7 +/- 2.4) months and (9.9 +/- 2.8) months, respectively; P < 0.05]. The postoperative shoulder abduction was 62.8 degrees +/- 12.6 degrees after transfer of the spinal accessory nerve, better than that after the traditional (51.6 degrees +/- 15.7 degrees). All the 11 patients could extend and externally rotate the shoulder almost normally. CONCLUSIONS: The accessory nerve transfer through dorsal approach is a safe and reliable procedure for the treatment of brachial plexus injury. Its postoperative effect is confirmed, which is better than that of the traditional operation.

Sacral anterior root stimulated defecation in spinal cord injuries: an experimental study in canine model.

AIM: To investigate whether there was a dominant sacral root for the motive function of rectum and anal sphincter, and to provide an experimental basis for sacral root electrically stimulated defecation in spinal cord injuries. METHODS: Eleven spinal cord injured mongrel dogs were included in the study. After L4-L7 laminectomy, the bilateral L7-S3 roots were electrostimulated separately and rectal and sphincter pressure were recorded synchronously. Four animals were implanted electrodes on bilateral S2 roots. RESULTS: For rectal motorial innervation, S2 was the most dominant (mean 15.2 kPa, 37.7% of total pressure), S1 (11.3 kPa, 27.6%) and S3 (10.9 kPa, 26.7%) contributed to a smaller part. For external anal sphincter, S3 (mean 17.2 kPa, 33.7%) was the most dominant, S2 (16.2 kPa, 31.6%) and S1 (14.3 kPa, 27.9%) contributed to a lesser but still a significant part. Above 85% L7 roots provided some functional contribution to rectum and anal sphincter. For both rectum and sphincter, the right sacral roots provided more contribution than the left roots. Postoperatively, the 4 dogs had electrically stimulated defecation and micturition under the control of the neuroprosthetic device. CONCLUSION: S2 root is the most dominant contributor to rectal pressure in dogs. Stimulation of bilateral S2 with implanted electrodes contributes to good micturition and defecation in dogs.

Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle.

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.

[Comparison of plate and Kirschner wire fixation in treatment of clavicular nonunion].

OBJECTIVE: To compare the results of plate and Kirschner wire fixation in treatment of nonunion of clavicular fracture. METHODS: From September 1991 to January 2002, 19 patients (9 with plate and 10 with Kirschner wire) were treated. The results were evaluated by reduction, bone union time, recovery of joint function, pain, and correction of deformation. RESULTS: The follow-up time was 6-23 months with an average of 11 months. Bone union occurred after a mean time of 11 weeks. In plate group, 7 patients gained excellent results, 1 good and 1 fair. In Kirschner wire group, 3 patients gained excellent results, 3 good, 3 fair and 1 poor. The result of plate is significantly better than that of Kirschner wire fixation(P < 0.05). CONCLUSION: Plate fixation is a good simple method for treatment of nonunion of clavicular fracture.